Trabeculectomy Medical Transcription Sample Report


DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Primary open-angle glaucoma, right eye.

POSTOPERATIVE DIAGNOSIS:
Primary open-angle glaucoma, right eye.

OPERATION PERFORMED:
Trabeculectomy, right eye.

SURGEON:  John Doe, MD

ANESTHESIA:
Local using solution of equal parts of 2% Xylocaine and 0.75% Marcaine. The patient was also given general anesthesia standby.

INDICATIONS:
To control glaucoma.

DESCRIPTION OF OPERATION:
After the patient was given a peribulbar local anesthetic injection, she was routinely prepped and draped. Steri-Strips were used to separate the right eyelids. A 6-0 Vicryl suture was passed through the clear cornea just in front of the limbus at the 12 o'clock position as a traction suture to rotate the eyeball downwards. The conjunctiva and Tenon capsule were then incised with the tenotomy scissors 8 to 10 mm posterior to the limbus from 10 to 12 to 2 o'clock positions.

The dissection was carried forward until the limbus was reached. Bleeding was controlled with wet-field cautery. We also elected to use the 6-0 Vicryl suture through the tendon of the right superior rectus muscle as a further traction suture to get better exposure. We noted that from her previous cataract surgery, which was done many years ago, that there were still holes in the sclerae at about the 12 o'clock; therefore, we elected to do the sclerotomy flap slightly on the nasal side, that is in the superior nasal quadrant. Superblade was used to outline the sclerotomy incision measuring 2.8 mm in width and extending 2-3 mm posteriorly. At this point, 2 corneal shield sponges were soaked in 0.3 mg/mL of mitomycin C. These were placed under the conjunctiva and Tenon capsule and held there for a period of 1 minute. Then, the sponges were properly disposed off and the entire area copiously irrigated with balanced salt solution. The retina was protected throughout the procedure with a corneal shield. The crescent knife blade was used to dissect the scleral flap until the limbus was reached. We then used a 27 gauge needle to enter the anterior chamber under the sclerotomy flap. We also injected a small amount of regular Healon into the anterior chamber to maintain the chamber. The Express shunt was then inserted through the preplaced opening. This was done without any problems. We noticed that aqueous immediately flowed out of the eye. The sclerotomy flap was then closed with multiple interrupted 10-0 nylon sutures. On the temporal corner, we used the 10-0 nylon suture and tied it with a slipknot with the proximal end of the suture coming out under the conjunctivae to make sure the clear cornea in front of the limbus. We checked this sclerotomy flap very carefully and were satisfied that there was no obvious leakage. The traction suture through the superior rectus muscle tendon was then released. The conjunctiva and Tenon capsule were then closed very tightly using a running interlocking 8-0 Vicryl suture to make the watertight wound. The corneal shield was removed and the corneal traction suture was also removed.


At the end of the procedure, we noticed that the anterior chamber was deep and clear. These have been partially filled with regular Healon. The eye was then irrigated with 20 mg of Garamycin and 0.5 mL of Celestone. Maxitrol ointment was instilled. Steri-Strips and drapes were removed and the eye was covered with a dry dressing and Fox metal shield. The patient tolerated the procedure very well and left the operating room in good condition.





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